I have read the HIPPAA rights and authorization statements and give my consent for disclosure of my medical records related to treatment.

PLEASE STOP at the CHECK-OUT COUNTER before leaving our office

Co-pays are required on the date of service. As a part of our service we will submit your insurance claims, but cannot assure payment. You are fully responsible for unpaid balances for products purchased and services rendered.NO Personal checks accepted

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS DECLARTION

I hereby authorize release of any medical information necessary to process my insurance claim and also ASSIGN to the DOCTOR all payments from MEDICARE and/or other Insurance provider(s) for services rendered. I understand and agree to the above conditions.

INSURANCE ACKNOWLEDGEMENT

I understand that it is my responsibility to notify Desert Ophthalmology of any changes to my insurance. Failure to do so may reflect a balance on my account with Desert Ophthalmology